Facts for Feedingis a series of publications from LINKAGES Project on recommended feeding and dietary practices to improve nutritional status at
various points in life cycle. This issue focuses on the infant's first six months of life. Policy makers, health care providers, and
communicators can use these guidelines for developing messages and activities appropriate to local conditions.

Local assessments should be conducted to determine the emphasis to give to each of the recommended feeding practices, to identify audiences that are most
receptive to change, and to design messages and activities based on audience profiles. Experience shows that focusing on a limited set of very
specific behaviors is key to improving nutrition.

Good attachment is important to enable the infant to suckle effectively, remove milk efficiently, and stimulate an adequate milk supply.

More areola (dark area around nipple) is visible above the baby's mouth than below.

Baby's mouth is wide open and the lower lip curled outwards.

Baby's chin touches the breast.

Baby takes slow, deep sucks, sometimes pausing.

Suckling is comfortable and pain free.

To ensure good attachment, the baby needs to be well positioned.

Baby's head and body are straight, not bent or twisted.

Baby faces the breast and reaches up to take the breast (baby should be able to look up at the mother's face, not flat to her chest or abdomen).

Baby is close to the mother.

Baby's whole body is supported, not just the head and shoulders.

To encourage effective suckling and to prevent the introduction of contaminants, no bottles or pacifiers (dummies or artificial teats)
should be used. If a mother has to miss a breastfeed, she can maintain her supply by expressing milk when she would have breastfed. Expressed
breastmilk can be fed by cup at a later time.

3 Breastfeed exclusively for the first six months

Breastmilk should be a baby's first taste. There should be no prelacteal feeds such as water, other liquids, or ritual foods.

Breastmilk completely satisfies an infant's nutritional and fluid needs for the first six months. Infants do not need water
or other liquids such as herbal teas to maintain good hydration, even in hot climates. The potential dangers of water supplementation include the
introduction of contaminants and reduced nutrient intake.

Exclusively breastfed children are at a much lower risk of infection from diarrhea and acute respiratory infections than infants who receive
other foods. Offering foods to infants before six months reduces breastmilk intake and interferes with full absorption of breastmilk nutrients.

Exclusive breastfeeding contributes to a delay in the return of fertility.

4 Practice frequent, on-demand breastfeeding, including night feeds

Babies should be fed on demand, as often as they want, day and night. This is usually 8– 12
times in 24 hours, though there may be intervals between feeds that are longer or shorter than 2– 3 hours.

An infant's stomach is small and needs to be refilled often. Breastmilk is perfectly adapted to the baby's small stomach size because it is easily digested.

Frequent feedings help maintain the mother's milk supply, maximize the contraceptive effect, and provide immune factors at each feeding.
They also help to prevent problems, such as breast engorgement, that might discourage a woman from breastfeeding.

If a baby urinates at least six times in 24 hours, this is a sign that breastmilk intake is adequate. If not, more
breastfeeding is necessary, or breastfeeding technique should be assessed.

5 Offer second breast after infant stops feeding from the first breast

Infants should continue feeding until they release the breast. This way they get the water and nutrient-rich "fore milk" at the start of the feed and the fat, rich "hind milk" at the end of the feed.

When offered the second breast, infants should be left to decide whether to continue feeding.

6 Continue breastfeeding when the mother or infant is sick

Breastmilk protects infants against illness. A mother who is sick with a cold, flu, or diarrhea does not pass the germs to her infant through breastmilk.

When an infant is sick, the mother should breastfeed more frequently. Breastmilk replaces water and nutrients lost through frequent loose stools.

7 In areas where vitamin A deficiency occurs, lactating women should take a high-dose vitamin A supplement (200,000 IU)* as soon as possible after delivery, but no later than 8 weeks postpartum, to ensure adequate vitamin A content in breastmilk

The concentration of vitamin A in breastmilk depends on a woman's vitamin A status and the changing needs of her growing infant. Preterm
infants and infants born in areas where vitamin A deficiency is prevalent are at particular risk of vitamin A deficiency.

The earlier the single high-dose vitamin A supplement is given to a lactating woman, the sooner the vitamin A status of her breastfed child will improve.

Beginning around eight weeks after childbirth, women are at heightened risk of pregnancy (especially if they are not fully breastfeeding).
Because a high-dose vitamin A supplement can be harmful to a fetus, women should not be given the high-dose supplement any time after eight weeks postpartum.

8 Continue on-demand breastfeeding and introduce complementary foods beginning at 6 months of age (see Facts for Feeding: Guidelines for Appropriate Complementary Feeding of Children 6-24 Months of Age)

Although most women in developing countries initiate breastfeeding, the
promotion of breastmilk substitutes, changing societal values, urbanization, and
the erosion of traditional support systems pose threats to
breastfeeding. The benefits of breastfeeding and the differences between
breastmilk and breastmilk substitutes need to be repeated to reinforce the
message, educate new audiences, and sustain individual behavior change.

Nutritional Benefits

Meets all of an infant's nutritional requirements for the first six months and is superior to any substitute.

Changes in composition to meet baby's changing needs.

Continues to be an important source of high quality protein, energy,
vitamins (especially vitamin A), minerals, and fatty acids for older infants and toddlers.

Health Benefits

For infant: Protects against illnesses and enhances the baby's immune system, providing long-term protection against diabetes and cancer.

For mother:Reduces risk of maternal postpartum hemorrhage.

Helps shrink the uterus back to normal size.

Delays return of menses, which helps to protect mother against anemia by conserving iron.

Reduces risk of developing premenopausal breast and ovarian cancer.

Knowledge of the health benefits of breastfeeding is usually inadequate to motivate women to adopt
optimal practices. To make better feeding choices, mothers need specific, culturally appropriate information that responds
to their constraints and concerns.

Child Spacing Benefits

During the first six months, frequent and intense breastfeeding can delay resumption of ovulation and return of menses, thereby decreasing
the likelihood of pregnancy during the period of lactational amenorrhea. Longer intervals between births bring health benefits to the mother
and the child, allow more time and resources for care of the child and siblings, and contribute to the economic well-being of the household.

The lactational amenorrhea method (LAM) provides another family planning option for women who meet three criteria: full breastfeeding, no return
of menses, and less than six months postpartum. If any one of these criteria is not met, another family planning method must be used to ensure
adequate birth spacing of three years.

Psychological and Developmental Benefits

Economic Benefits

Environmental Benefits

Conserves natural resources and reduces pollution.

Barriers to improved breastfeeding practices should be addressed by ensuring a favorable
policy environment, providing accurate information, offering practical help and encouragement, and creating social support.

Health Services

Take advantage of the numerous opportunities to promote and support optimal breastfeeding practices in child survival, primary health care, and family
planning programs.

Prenatal and Postpartum Care:
Include as part of prenatal care a breast exam, a breastfeeding history, and counseling on the benefits of exclusive breastfeeding, early initiation
of breastfeeding, and colostrum. Provide counseling on the lactational amenorrhea method as a family planning method. If
another method is desired, encourage using one that does not interfere with breastfeeding.

Training

Support the training of health care providers in lactation management skills, as well as curriculum modification in professional schools to include lactation management education.

Policies

Establish, enforce, and/ or support policies that regulate and monitor the marketing and use of
breastmilk substitutes. Set standards of care in health care institutions.

Workplace

Promote "Mother-Baby Friendly" workplaces and public locales. Advocate for family leave and the availability of appropriate areas for milk expression or breastfeeding.

Community

Promote and affiliate with community-based breastfeeding support activities: peer counselors,
mother-to-mother support groups, and community education networks. Use social marketing techniques to develop effective breastfeeding messages to spread
throughout the community.

Women's Nutrition

Ensure adequate nutritional status during pregnancy and lactation, as well as during adolescence and between pregnancies, to build up and maintain
energy and micronutrient reserves.

Educational Materials

Ensure the availability of culturally appropriate and easily understood
educational materials for adolescent girls and women of child-bearing age and their families. Messages should address concerns
about water requirements of infants, mothers' doubts about the adequacy of their breastmilk, and other issues, such as employment, that may act as barriers to exclusive breastfeeding.

* This recommendation is currently under review and may be increased, pending the results of ongoing research.

Facts for Feeding - Recommended Practices to Improve Infant Nutrition during the First Six Monthsis a
publication by LINKAGES: Breastfeeding, LAM, Related Complementary Feeding, and Maternal
Nutrition Program, and was made possible through support provided to the Academy for
Educational Development (AED) by the Bureau for Global Health of the United States Agency
for International Development (USAID), under the terms of Cooperative Agreement No. HRN-A-00-97-00007-00. The opinions expressed herein are
those of the author(s) and do not necessarily reflect the views of USAID or AED. Wellstart International contributed to the
development of the original publication.